Physician and Professional Services
Revised: 12-16-2015
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Physician Services
Outpatient Physician Administered Drug Reporting
Evaluation and Management Services (E/M)
Education and Counseling
Smoking Cessation Services
Medical Supplies Provided by a Physician Office
Casting Provided in a Physician Office
Immunizations and/or Vaccinations
EKG Interpretations
Acupuncture
Allergy Immunotherapy-Allergy Testing
Surgical Services
Locum Tenens Physicians
Reciprocal Billing
Telemedicine
Advanced Practice Registered Nurse (APRN) Services
Physician Assistants (PA)
Physician Extenders
Outpatient Hospital Services
Hospital Physician Services
Evidence-based Childbirth Program Policy
Authorization Policy
 Plastic and Reconstructive Surgery
 Botulinum Toxin
 Male Circumcision
 Hysterectomy
Transplant Services
Sleep Testing
Medical Nutritional Therapy (MNT)
Diabetic Self-Management Training (DSMT) Services
Nutritional Products
Covered Nutritional Services
Podiatry
Legal References
Pay-for-Performance Program
Review information about the newly implemented Pay-for-Performance Program.
Physician Services
Physician: A person who is licensed to provide health services within the scope of his or her profession
under Minnesota Statutes 147. For purposes of this section, a physician means a licensed doctor of
medicine or osteopathy.
Enrollment Requirements
Physicians must enroll with DHS to receive payment. Physicians must receive an individual National
Provider Identifier (NPI) even if they are a member of a group, clinic, employed by an outpatient hospital,
or other organized health care delivery system that employs physicians. (Refer to the Locum Tenens
section.)
Provider Type Home Page Links
Review related Web pages for the latest news and additions, forms, and quick links.
 Chemical Dependency
 Clinic/Physician & Physician/Clinic
 Clinical Nurse Specialist
 Community Health Clinic
 Fed. Qual. Health Center (FQHC)
 Hospital
 Indian Health Service/Facility & Tribal Social Services
 Managed Care & Prepaid Health Plans
 Medical Supply
 Nurse Practitioner
 Physicians Assistant
 Podiatrist
 Public Health Clinic (PHC)
 RN/LPN/Private Duty Nurse
Covered Services
Services provided by a physician are not restricted to a specific place of service unless specified by CPT
or HCPCS code description. Physicians may provide services in the recipient's home, nursing home,
outpatient hospital, inpatient hospital, or other facility.
Physicians may not bill separately for performing administrative or medical functions that are paid through
an institution's per diem rate.
A health service must be medically necessary in order to be a covered service. Services listed as
provided by a physician in this chapter may be provided by other health care professionals if the service
is within the scope of their practice as defined in the Minnesota Statues.
Outpatient Physician Administered Drugs
Drugs that are administered to a patient as part of a clinic or other outpatient visit should be billed to
MHCP using the appropriate HCPCS code(s). Do not bill drugs administered during an outpatient visit
through the pharmacy POS system. MHCP does not allow “brown-bagging” or “white-bagging” of
prescription drugs administered in an office setting.
Pharmacies, including mail order pharmacies, who are providing the drugs for a clinic visit, should bill the
clinic and not MHCP for the drugs dispensed. MHCP will make an exception only if a recipient has thirdparty liability and the third-party payer requires that the drugs be billed through the pharmacy benefit.
Pharmacies should not dispense drugs directly to a patient if the drugs are intended for use during a clinic
or other outpatient visit.
Outpatient Physician Administered Drugs NDC Reporting
The federal Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for covered outpatient
drugs administered by “physicians”. In order to comply, states must gather utilization data including the
National Drug Code (NDC), quantity, and unit of measure from claims submitted for physicianadministered drugs.
Include the correct NDC information on all claims, including Medicare and other third party claims, when
billing non-vaccine drugs using HCPCS codes. Participants in the 340B Drug Pricing Program are
included in the NDC reporting requirements; however, drugs purchased through 340B are exempt from
NDC reporting. Add the UD modifier to drugs purchased through the 340B Program. Refer to the HCPCS
Codes Requiring NDC when submitting claims for reimbursement.
NDC reporting of Outpatient Physician Administered Compound Drug
Enter one compound drug (HCPCS code) per claim transaction with up to 25 individual NDC’s in the Drug
Identification loop, The NDC quantity and dose form are reported in the Quantity and Unit or Basis for
Measurement Code or on MN–ITS Interactive in the Drug Pricing field on the Services Tab.
Reporting the Wasted Portion of Administered Drugs
The submitted line should include the amount discarded with the amount administered. Providers are
expected to use the package size that minimizes the amount of waste billed to MHCP. For example, if a
patient needs 50 mg of drug and the product comes in 50 mg and 100 mg vials, use the 50 mg vial unless
the rest of the 100 mg vial will be used for another patient scheduled for treatment the same day. Both
MHCP and Medicare encourage scheduling patients to make the most efficient use of the drugs
administered.
Authorization Requirements
Contact Health Information Designs (HID), the MHCP Prescription Drug PA review agent when providing
a physician administered drug that requires authorization. All authorization requests will require a primary
diagnosis and may require supporting documentation.
Submit authorization requests in one of these ways:
 Call the MHCP Prescription Drug Prior Authorization Agent
 Complete the paper MHCP Authorization Form (DHS-4695) or the MHCP Drug Authorization Form
(DHS-4422)
 Complete the medical services authorization (PDF) online via MN–ITS
 Fax completed authorization forms or MN–ITS Authorization request response and documentation to
the MHCP Prescrption Drug Prior Authorization Agent
Evaluation and Management Services (E/M)
MHCP follows CPT guidelines for Evaluation and Management Services.
Concurrent Care
Concurrent Care Services: The provision of similar services (for example, hospital visits to the same
patient by more than one physician on the same day). If a consulting physician subsequently assumes
the responsibility for a portion of patient management, it is considered concurrent care.
MHCP pays concurrent care when the medical condition of the recipient requires the services of more
than one physician. Generally, a recipient's condition that requires physician input in more than one
specialty area establishes medical necessity for concurrent care.
Noncovered Concurrent Care Services
MHCP will not pay for concurrent care when one of the following occur:
 The physician makes a routine call at the request of the recipient and family or as a matter of
personal interest
 Available information does not support the medical necessity of concurrent care
Consultations
MHCP follows CPT guidelines for Office, Outpatient and Inpatient consultations.
Critical Care
Follow CPT guidelines for reporting critical care. Services not included in Critical Care may be reported
separately.
Observation Services
Report using hospital observation codes following CPT guidelines.
Up to 48 hours of observation services are allowed, and in some circumstances up to 72 hours.
Physician Services While Recipient is Inpatient Status
For procedures done while the patient is considered in an inpatient status, use place of service code 21
(inpatient hospital).
Physician Services in Long-Term Care (LTC) Facilities
Payment for physician and professional services in an LTC must be medically necessary. Refer to the
Physician Extender section of this chapter for use of physician extender services provided in LTC
facilities. Refer to MHCP Long-Term Care policy for additional information on covered services in LTC
facilities.
Prolonged Physician Services
Prolonged services involving direct (face-to-face) patient contact are covered. Use CPT guidelines to
report Prolonged Services.
Physician Standby Services
Standby services are covered when requested by another physician and involve prolonged attendance
without direct (face-to-face) patient contact. Standby services are covered only in the case of a
documented existing risk or distress.
Physician Case Management (Team Conferences)
A medical team conference conducted for the purpose of coordinating the activities of a recipient's care
with an interdisciplinary team of health professionals or a representative of community agencies is a
covered service.
The medical record must document the contents of the conference and the amount of time spent in the
conference.
Bill the appropriate CPT E/M code.
Medical Conference or Counseling (as part of E/M code)
Physician services related to counseling are covered as part of the E/M codes if the counseling is
conducted face-to-face with the patient, relative, or guardian.
When counseling or coordination of care dominates (more than 50%) the encounter between the
physician and the patient or family, time may be considered the key or controlling factor to qualify for a
particular level of E/M service. Medical record documentation must reflect the content of the counseling,
coordination of care, and the amount of time spent in counseling/coordination.
Telephone Calls
Telephone calls are not covered by MHCP.
Care Plan Oversight
Care plan oversight services are not covered by MHCP.
Preventive Medicine Services
Preventive Health Services: A health service provided to a patient to avoid or minimize the occurrence or
recurrence of illness, infection, disability, or other health condition. Follow CPT guidelines for billing
preventive health services.
MHCP covers Grade A and B preventive services recommended by the United States Preventive
Services Task Force.
Noncovered Preventive Services
The following services are not covered as a preventive service:
 Services that are only for vocational or educational purposes that are not health related
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Services that deal with external, social, or environmental factors that do not directly address the
recipient's physical or mental health
Preventive Medicine Services or Counseling, and Risk Factor Reduction
Preventive health counseling to promote health and prevent illness or injury is a covered service. Bill for
these services with the appropriate E/M code for preventive medicine, individual counseling, and group
counseling.
Education and Counseling
Eligible Providers
Eligible providers include: enrolled physicians, physician clinics, community clinics, outpatient hospitals,
public health clinics, family planning agencies, certified nurse practitioners, physician assistants, clinical
nurse specialists, certified nurse midwives, community mental health centers, and physician extenders.
Covered Education or Counseling Services
Reason for Education or
HCPCS
Counseling
Code(s)
Education or counseling is the
99401–99409
primary reason for the visit.
(individual)
Services to healthy individuals
for the purpose of promoting
99411–99412
health and anticipatory guidance (group)
(i.e., family planning, smoking
cessation, infant safety, etc.).
Education or counseling is the
primary reason for the visit.
Services to people with
symptoms, a diagnosis or
established illness (i.e., prenatal,
joint care, pain, HIV, asthma).
Refer also to nutritional, diabetic
and weight reduction guidelines.
Education or counseling is an
add-on to the office visit (e.g., if
provided as part of the regular
office visit and dominating more
than 50% of the clinician/patient
visit, then time may be
considered the key or controlling
factor to qualify for a particular
level of E/M service.)
Asthma education, per session.
Asthma education may be
reported outside of the office visit
when an asthma action plan
(AAP) has been written by the
clinician and discussed with the
patient or family, documented in
the medical record and a copy
provided to the asthma educator.
Birthing classes per session.
98960
(individual)
98961–62
(group)
99201–99205
(new patient)
Eligible Providers
Billing Directions
Physicians
Enrolled PAs and APRNs
(NPs, CNSs, CNMs)
Physician extenders: nonenrolled APRNs, RNs,
genetic counselors, licensed
acupuncturists, tobacco
cessation counselors and
pharmacists
Enrolled PAs and APRNS
(NPs, CNSs, CNMs)
Physician extenders (nonenrolled APRNs, RNs,
genetic counselors, licensed
acupuncturists)
Use modifier U7
when a physician
extender providers
the service.
Use modifier U7
when a physician
extender provides
the service.
Physicians
Enrolled PAs and APRNs
(NPs, CNSs, CNMs)
99211–99215
(established
patient)
S9441
S9442
Asthma education may be
reported with S9441 by
using the supervising
clinicians’ NPI for one of the
following:
Non-enrolled APRNs (NPs,
CNSs, CNMs);
RNs; and pharmacists.
Certified Asthma Educators
(CAE)
Clinics and outpatient
Bill one unit for each
class.
Bill one unit for each
Lactation classes per session.
S9443
Enhanced prenatal services
provided to “at-risk” pregnant
women only. An at-risk
determination is based on the
results of a prenatal risk
assessment (e.g., ACOG’s
Obstetric Medical history).
H1003
Counseling to assess and
minimize problems hindering
normal nutrition, and to improve
the patient’s nutritional status.
97802 – initial
individual
Reassessment due to change in
diagnosis, medical condition or
treatment regimen requiring a
second referral in the same year.
Diabetic Outpatient Selfmanagement Training services
(DSMT) including education
about self-monitoring blood
glucose, diet, exercise, and
sliding scale insulin treatment for
the patient who is insulin
dependent.
hospitals whose prenatal
education program is
directed by an MHCP
enrolled provider may report
S9442, S9443 and H1003
with one of the following:
Non-enrolled APRNs (NPs,
CNSs, CNMs)
RNs
Health educators with at
least a baccalaureate level
degree in health education
or national certification with
ICEA, Lamaze or NCHEC
for prenatal certification or
IBCLC for lactation
certification
Physicians
Licensed dieticians
Licensed nutritionist
time the class
meets.
Bill one unit for each
time the class
meets.
Bill one unit for the
entire class: 3 wks of
nutrition education =
1 unit.
Physicians
RNs
Licensed dieticians
Licensed nutritionist
Bill 15 minute unit.
MNT is reimbursed
when a licensed
dietician or
nutritionist is under
the supervision of a
physician.
Bill 30 minute unit.
97803 –
reassess
individual
97804 – group
G0270 –
individual
G0271 –
group
G0108 –
individual
G0109 –
group
Physicians
RNs
Licensed dieticians
Licensed nutritionist
A provider of dually eligible
Medicare and MHCP
recipients must be a
“certified provider” according
to the National Diabetes
Advisory Board Standards.
Bill 15 minute unit.
MNT is reimbursed
when a licensed
dietician or
nutritionist is under
the supervision of a
physician.
Initial training 10
hour limit per 12
months
Additional training
limited to 1 hour per
year.
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Refer to the Community Health Worker (CHW) section of the manual for the MHCP covered education
services provided by a CHW.
Noncovered Services
Services provided as part of a day treatment program, partial hospitalization, or other similar health care
programs may not be billed as physician services provided in an educational or counseling setting.
Documentation
A physician order for educational or counseling services is required. Documentation of the recipient's
participation, number of participants in the educational or counseling group, name and credentials of
person who provided the service and topic content must be in the medical record or class record.
Billing
Refer to the following billing guidelines:.
 The cost of educational materials is included in the payment; no additional payment will be made for
handouts, textbooks, or other materials.
 Physician extenders must modify their services using the appropriate modifier. (Refer to the Physician
Extender section.)
Smoking Cessation Services
MHCP covers smoking cessation education, counseling and products when they are ordered by a primary
care provider and provided by an MHCP enrolled provider or Physician Extender. Smoking cessation
products must be approved by the Food and Drug Administration (FDA) and covered under the Medicaid
Drug Rebate Agreement. Prescriptions for smoking cessation products are subject to quantity limits.
Prescriptions may not be dispensed for quantities in excess of the FDA-approved dose for any smoking
cessation product. See also the DHS QUITPLAN Services page.
Medical Supplies Provided by a Physician Office
Eligible Providers
For the purpose of this chapter, the following are eligible providers: physicians, APRNs, PAs, and
physician clinics.
Payment Limitations
Payment limitations for medical supplies provided by a physician’s office are the same as for medical
supplies. Refer to MHCP Equipment and Supplies policy. Routine supplies are not paid separately.
Supplies applied or used in the physician’s office or clinic in direct relationship to an illness or injury are
generally considered incident to the service and are not separately billable to DHS.
Noncovered Services
Supplies sent home with the recipients are not covered by MHCP.
The following is a list of routine physician office supplies which cannot be billed separately. This is not an
all-inclusive list:
Adhesive tape, all sizes
Alcohol or peroxide, per pint
Alcohol wipes
Autolet
Band-Aids
Betadine, Iodine, Providine swabs/wipes
Betadine, Phisohex, per pint
Chux pads
Cold packs
Cotton balls
Cotton tip application (sterile/non-sterile)
Culturette
Emesis basins
Enema kits
Gauze pads, sterile or non-sterile
Gelfoam
Gloves (latex, plastic, rubber, sterile, etc.)
Gowns
Hemostatic cellulose (e.g., surgical, any size)
IVP dyes
Kerlix, Kling bandages
Masks
Micropourous tape
Needles, sterile
Opsite
Patient electrode pads
Razor
Sanitary belt/napkins, tampons
Silver nitrate stick
Specimen collection
Steri-strips
Sterile saline, 30cc
Sterile water, 30cc
Suction tubing
Surgical drapes
Suture removal tray
Syringe (with/without needles)
Thermometer (any size)
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Casting Provided in a Physician Office
If no surgery or manipulation is done, bill the appropriate E/M code and HCPCS casting supply code.
If surgery or manipulation is done, bill the appropriate CPT surgery code and HCPCS casting supply
code.
If recasting is done, bill the appropriate CPT casting code and HCPCS casting supply code.
Immunizations and Vaccinations
MHCP covers vaccines, toxoids, and an administration fee.
MHCP covers only the administration fee for vaccines and toxoids provided free by the Minnesota
Vaccines for Children (MnVFC), available through the Minnesota Department of Health (MDH). Most
routine childhood vaccines and some adult vaccines are available through the MnVFC program. Refer to
the Immunizations & Vaccinations section of the Provider Manual.
EKG Interpretations
EKG interpretation services may be billed in addition to the E&M service. MHCP covers one physician
interpretation for each EKG.
Allergy Immunotherapy-Allergy Testing
Antigen: The raw form of pollen, (venom, stinging insect, etc.) prior to refinement for administration to
humans.
Allergenic Extract: The refined injectable form of antigen either commercially prepared or refined in the
physician's office under his or her supervision.
Immunotherapy: The parenteral administration of allergenic extracts as antigens at periodic intervals,
usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.
Covered Services
MHCP covers the following allergy immunotherapy or allergy testing services:
 Professional services to prepare raw antigen to a refined state that will become an allergenic extract
 Professional services to administer the allergenic extract
 Providing the injectable allergenic extract
 Physician ordered allergen immunotherapy and services performed by the physician or qualified
personnel under the direction of a physician
 Professional services to monitor the recipient's injection site and observe for anaphylactic reaction
 Allergy testing is covered when clinically significant symptoms exist and conservative therapy has
failed.
 Provision of inhalants (a pharmaceutical). Refer to MHCP Pharmacy Services policy
 Evaluation and Management services are eligible for separate payment on the same day as allergen
immunotherapy only when a significant, separately identifiable service is performed.
Noncovered Services
Testing
Allergy testing includes the performance, evaluation, and reading of cutaneous and mucous membrane
testing.
The physician work of taking a history, performing the physical examination, deciding on the antigens to
be used, interpretation of results, counseling and prescribing treatment should be reported using an
Evaluation and Management code.
The following allergy testing procedures are considered investigative, and therefore are not covered:
 Cytotoxic leukocyte testing (Brian's test)
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Leukocyte histamine release testing
Provocation-neutralization testing (sublingual, subcutaneous, intradermal, or intracutaneous);
Rebuck skin window test
Passive transfer or P-K Test (Prausnitz-Kustner)
Candidiasis hypersensitivity syndrome testing
IgG level testing General volatile organic screening test (volatile aliphatic panel)
ELISA/ACT immunotherapy (Serammune Physician Lab, Reston VA)
Antigen Leukocyte Cellular Antibody Test (ALCAT)
Treatment
The following allergy treatments are considered investigative and therefore are not covered:
 Provocation-neutralization treatment (sublingual, subcutaneous, intradermal or intracutaneous)
 Oral and sublingual immunotherapy (includes oral drops, solutions, oral capsules and tablets)
 Rinkel immunotherapy
 Autologous urine immunizations
 Clinical ecology urine immunizations
 Candidiasis hypersensitivity syndrome treatment and related services
 IV vitamin C therapy
 Enzyme potentiated desensitization
 Rhinophototherapy
 Poison Ivy/Poison Oak extracts for immunotherapy
 T.O.E. (Trichophyton, Oidiomycetes, and Epidermophyton immunotherapy for chronic otitis media)
Coverage Limitations
Allergenic extracts may be administered with either one or multiple injections. Documentation in the
medical record must support the number of injections administered.
Preparation of Raw Antigen to Allergenic Extract: Only physicians who perform the refinement of raw
antigens to allergenic extract may bill for this service. This service involves:
 Sterile preparation of an allergenic extract by titration, filters, etc.
 Checking the integrity of the extract by cultures or other qualitative methods
Neither purchasing refined antigens, measuring dosages nor adding diluent is considered "refining raw
antigens."
Adding Diluent: As in any other medication administration, it is not a separately covered service. This
service is an integral part of the professional services for providing an allergenic extract.
Identifiable services not included in an office visit may be billed separately.
Surgical Services
Global Surgery Package
The global surgical package period: Surgery and the time following surgery during which routine care
by the physician is considered postoperative and included in the surgical fee. Office visits or other routine
care related to the original surgery cannot be separately reported if the care occurs during the global
period. MHCP covers medically necessary surgical services. MHCP reimbursement for all surgeries is
based on a global surgery package, which follows Medicare global surgery guidelines and includes pre,
post, and intraoperative work related to the surgical procedure. MHCP follows Medicare guidelines for the
number of days in the global package. Preoperative physicals by a primary physician are not included in
the global package. Evaluation of the need for surgery by the surgeon is also covered outside of the
global surgical package.
The visit identifying the need for surgery is not included in the global fee even if occurring on the
preoperative day, or on the day of surgery. Use CPT modifier 57 to bill the E/M service for established
patient visit or consultation the day before or the day of major surgery when the decision for surgery is
made during the visit.
E/M services provided on the same day as the procedure are generally not payable unless they are
significant, separately identifiable, and billed with modifier 25.
Postoperative care includes the following:
 Evaluation and management services
 Pain management
 Treatment of complications (e.g., treatment of infection related to the surgery)
 Miscellaneous service: dressing changes and local incisional care; removal of operative pack,
cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and
removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and
changes/removal of tracheostomy tubes
Complications
Complications requiring additional services from the surgeon that do not require a return trip to the
operating room are included in the global payment. Surgical complications requiring a return to the
operation room are not included in the global fee. Report complications requiring a return trip to the
operating room with modifier 78 appended to the original procedure code.
If further specifics are required, refer to the Medicare global surgery guidelines.
Assistant-at-Surgery
MHCP follows Medicare's assistant-at-surgery guidelines. MHCP does not cover assistant-at-surgery
services provided by surgical technicians, surgical assistants or RN first assists (RNFA).
MD assistant surgeons must bill using modifier 80 or 82. Physician assistants, clinical nurse specialists
and Advance Practice Registered Nurses (APRN) must use the modifier AS.
Billing
Refer to the following billing guidelines for physician services:
 Use the 837P for physician services at surgery
 Refer to MHCP Tribal and Federal Indian Health Services policy for physician services provided in an
IHS facility.
Bilateral Procedures – Modifier 50
Use modifier 50 only when the exact same service or code is reported for each bilateral anatomical site:
 Report bilateral surgical procedure codes on one line appended with modifier 50
 Enter 1 unit on a line reported with modifier 50 (Example: 49500 – 50 – 1 unit)
 Do not use modifier 50 with procedure codes that are identified as bilateral or for codes that use the
words one or both within the code description
Locum Tenens Physicians
Locum Tenens Physician: MHCP recognizes that physicians often retain a substitute physician to take
over their professional practices while they are absent for reasons such as illness, vacations, continuing
medical education and pregnancy.
MHCP further recognizes locum tenens arrangements and pays the regular physician for the services
provided by the substitute physician if:
 The regular physician is unavailable to provide services
 The recipient has arranged or seeks to receive the services from the regular physician
 The regular physician pays the locum tenens physician on a per diem or a fee-for-service basis
 The locum tenens physician does not provide services over a continuous period of longer than 60
days
Covered Services
MHCP covers locum tenens physician services using Medicare guidelines. Locum tenens services
provided by an APRN are covered. Current licensure is required.
Documentation
The regular physician must keep a record of each service provided by the locum tenens physician along
with the substitute physician’s NPI.
Billing
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Refer to the following billing guidelines for locum tenens physicians:The recipient's regular physician
bills and receives payment for locum tenens physician covered services. Compensation paid by a
medical group is considered paid by the physician.
The locum tenens physician does not have to be identified on the claim or need to enroll with DHS.
Bill with modifier Q6.
Postoperative services performed by the locum tenens physician during the global surgery period do
not require a Q6 modifier (if the services are only in connection with the surgery).
Reciprocal Billing
Reciprocal Billing Arrangements: A recipient’s regular physician may submit a claim for a covered
service that the regular physician arranges to be provided by a substitute physician on an occasional
reciprocal basis if:
 The regular physician is unavailable to provide the visit services
 The recipient has arranged or seeks to receive services from the regular physician
 The substitute does not provide services over a continuous period of longer than 60 days
These requirements do not apply to the substitution arrangements among physicians in the same medical
group where claims are submitted in the name of the group. On claims submitted by the group, the group
physician who actually performed the services must be identified as the rendering physician.
Covered Services
MHCP covers substitute physician services using Medicare guidelines.
Documentation
The regular physician must keep a record of each service provided by the substitute physician along with
the substitute physician’s UPIN.
Billing
Refer to the following billing guidelines for reciprocal billing:
 The regular physician bills and receives payment for substitute physician covered services.
 The substitute physician does not have to be identified on the claim nor enrolled with DHS.
 Bill with modifier Q5.
 Postoperative services performed by the substitute physician during the global surgery period do not
require a Q5 modifier (if the services are in connection with the surgery).
Telemedicine
Telemedicine is defined as the delivery of health care services or consultations while the patient is at an
originating site and the licensed health care provider is at a distant site.
To be eligible for reimbursement, providers must self-attest that they meet all of the conditions of the
MHCP telemedicine policy by completing the Provider Assurance Statement for Telemedicine (DHS6806) (PDF).
Effective Jan. 1, 2016, MHCP allows payment for expanded telemedicine services. Payment is allowed
for the following services:
 Interactive audio and video telecommunications that permit real-time communication between the
distant site physician or practitioner and the recipient. The services must be of sufficient audio and
visual fidelity and clarity as to be functionally equivalent to a face-to-face encounter.
 "Store and Forward": The asynchronous transmission of medical information to be reviewed at a
later time by a physician or practitioner at the distant site. Medical information may include, but is not
limited to, video clips, still images, x-rays, MRIs, EKGs, laboratory results, audio clips and text. The
physician at the distant site reviews the case without the patient being present. Store and forward
substitutes for an interactive encounter with the patient present; the patient is not present in real-time.
Originating Site
The originating site is the location of an eligible MHCP recipient at the time the service is being furnished
via a telecommunication system. Authorized originiating sites are listed below:
 Office of physician or practitioner
 Hospital (inpatient or outpatient)
 Critical access hospital (CAH)
 Rural health clinic (RHC) and Federally Qualified Health Center (FQHC)
 Hospital-based or CAH-based renal dialysis center (including satellites)
 Skilled nursing facility (SNF)
 End-stage renal disease (ESRD) facilities
 Community mental health center
 Dental clinic
 Residential facilities, such as a group home and assisted living
 Home (a licensed or certified health care provider may need to be present to facilitate the delivery of
telemedicine services provided in a private home)
 School
Eligible Providers
The following provider types are eligible to provide telemedicine services:
 Physician
 Nurse practitioner
 Physician assistant
 Nurse midwife
 Clinical nurse specialist
 Registered dietitian or nutrition professional
 Clinical psychologist
 Clinical social worker
 Dentist
 Pharmacist
 Certified genetic counselor
 Podiatrist
 Speech therapist
 Physical therapist
 Occupational therapist
 Audiolgist
Eligible Recipients
Telemedicine coverage applies to MHCP recipients in fee-for-service programs. Prepaid health plans may
or may not choose to pay for services delivered in this manner.
List of Telemedicine Services
The CPT and HCPC codes that describe a telemedicine service are generally the same codes that
describe an encounter when the health care provider and patient are at the same site. Examples of
telemedicine services include but are not limitied to the following:
 Consultations
 Telehealth consults: emergency department or initial inpatient care
 Subsequent hospital care services with the limitation of one telemedicine visit every 30 days per
eligible provider
 Subsequent nursing facility care services with the limitation of one telemedicine visit every 30 days
 End-stage renal disease services
 Individual and group medical nutrition therapy
 Individual and group diabetes self-management training with a minimum of one hour of in-person
instruction to be furnished in the initial year training period to ensure effective injection training
 Smoking cessation
 Alcohol and substance abuse (other than tobacco) structured assessment and intervention services
Billing Telemedicine Services
MHCP enrolled providers submit claims for telemedicine services using the CPT or HCPC code that
describes the services rendered. The following modifiers must also be included:
 GT (via interactive audio and video telecommunications systems)
 GQ (via asynchronous telecommunication system)
When reporting a service with the GT modifier, the provider is certifying that they are rendering services
to a patient located in an eligible originating site via an interactive audio and visual telecommunications
system
General
In addition to other requirements, refer to the following general telemedicine information:
 Out-of-state coverage policy applies to services provided via telemedicine. Consultations performed
by providers who are not located in Minnesota and contiguous counties, require authorization prior to
the service being provided
 Payment will be made for only one reading or interpretation of diagnostic tests such as x-rays, lab
tests, and diagnostic assessments
 Payment is not available to providers for sending materials to recipients, other providers or facilities
Two-Way Interactive Video Consultation in an Emergency Room (ER)
Two-way interactive video consultation may be billed when no physician is in the ER and the nursing
staff is caring for the patient at the originating site. The ER physician at the distant site bills the ER CPT
codes with the GT modifier. Nursing services at the originating site would be included in the ER facility
code.
If the ER physician requests the opinion or advice of a specialty physician at a "hub" site, the ER
physician bills the ER CPT codes without the GT modifier. The consulting physician bills the consultation
E/M code with the GT modifier.
Coverage Limitations
The following limitations apply:
 Payment for telemedicine services is limited to three per week per recipient
 Payment is not available for sending materials to a recipient, other provider or facility
The following are not covered under telemedicine:
 Electronic connections that are not conducted over a secure encrypted website as specified by the
Health Insurance Portability & Accountabiliyt Act of 1996 Privacy & Security rules (e.g., Skype)
 Prescription renewals
 Scheduling a test or appointment




Clarification of issues from a previous visit
Reporting test results
Non-clinical communication
Communication via telephone, email or facsimile
Advanced Practice Registered Nurse (APRN) Services
An Advanced Practice Registered Nurse (APRN) is an individual licensed as a registered nurse by the
Minnesota Board of Nursing and certified by a national nurse certification organization acceptable to the
Minnesota Board of Nursing to practice as a clinical nurse specialist, nurse anesthetist, certified nursemidwife, or nurse practitioner. The practice of advanced practice registered nursing also includes
accepting referrals from, consulting with, cooperating with, or referring to all other types of health care
providers, including but not limited to physicians, chiropractors, podiatrists, and dentists, provided that the
APRN and the other provider are practicing within their scopes of practice as defined in state law.
Certified registered nurse anesthetist practice: The provision of anesthesia care and related services
within the context of collaborative management, including selecting, obtaining, and administering drugs
and therapeutic devices to facilitate diagnostic, therapeutic, and surgical procedures upon request,
assignment, or referral by a patient's physician, dentist, or podiatrist.
Clinical nurse specialist practice (CNS): The provision of patient care in a particular specialty or
subspecialty of advanced practice registered nursing within the context of collaborative management, and
includes: (1) diagnosing illness and disease; (2) providing nonpharmacologic treatment, including
psychotherapy; (3) promoting wellness; and (4) preventing illness and disease. The certified clinical nurse
specialist is certified for advanced practice registered nursing in a specific field of clinical nurse specialist
practice.
Nurse practitioner practice: Practice within the context of collaborative management: (1) diagnosing,
directly managing, and preventing acute and chronic illness and disease; and (2) promoting wellness,
including providing nonpharmacologic treatment. The certified nurse practitioner is certified for advanced
registered nurse practice in a specific field of nurse practitioner practice.
Certified nurse-midwife practice: The management of women's primary health care, focusing on
pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and
gynecological needs of women and includes diagnosing and providing nonpharmacologic treatment within
a system that provides for consultation, collaborative management, and referral as indicated by the health
status of patients.
Eligible Providers
DHS enrolls all APRNs listed above. Registered nurse certified (RN, C) is not eligible to enroll.
An enrolled CRNA, CNS, or NP receives 90 percent of the physician rate. An enrolled certified nursemidwife receives 100 percent of the physician rate.
Refer to Physician Extender policy for APRNs who choose not to enroll.
Covered Services
Services performed by APRNs are covered if the services are covered through MHCP and the services
are within the scope of practice for an APRN as described in Minnesota Statutes 148.171 through
148.285.
Billing
Bill for APRN services using HCPCS/CPT codes and follow MHCP requirements for covered physician
and professional services. Also note the following:
 For independently practicing enrolled APRNs, enter the APRN NPI as the billing provider.
 For organizations employing enrolled APRNs, enter the APRN NPI as the rendering provider.
Physician Assistants (PA)
Physician Assistant: A person registered pursuant to Minnesota Statutes 147A who is qualified by
academic or practical training or both to provide patient services as specified in Minnesota Statutes 147A
under the supervision of a supervising physician.
Eligible Providers
Enrolled PAs receive 90 percent of the physician rate and should not use the physician extender modifier
when billing DHS. The services of those who choose not to enroll will be paid as physician extender
services through the supervising physician at 65 percent of the physician rate and requires modifier U7
when billing MHCP.
Covered Services
Services performed by a PA are covered if otherwise, the services are a covered physician service, are
within the scope of practice for a PA as described in Minnesota Statutes 147A, and meet all required
criteria by the appropriate certifying, regulatory, or licensing entities. MHCP enrolls PAs as treating
providers not pay-to-providers.
Supervision of PAs
MHCP allows off-site or remote supervision of PAs, provided the terms of the physician/physician
assistant agreement are being met and the physician/physician assistant are, or can be, easily in contact
with one another by radio, telephone, or other communication device.
Off-site or remote supervision does not apply to Rural Health Clinics (RHCs) and Federally Qualified
Health Centers (FQHCs), which, under federal regulations, require that a physician is present for
sufficient periods of time, at least once every two-week period (except in extraordinary circumstances,
which must be documented in the records of the clinic) to provide the following:
 Medical direction
 Medical services
 Consultation
 Supervision
The physician must be available through direct telecommunication for consultation, assistance with
medical emergencies, and patient referral.
Billing
Bill PA services using the appropriate CPT/HCPCS codes. Follow these MHCP requirements for covered
physician services:
 Enter the NPI as the Rendering Provider
 Use the clinic or group name and address and NPI as the billing provider
 Non-enrolled PAs use modifier U7
 Physician assistants use modifier AS when assisting-at-surgery.
Noncovered
Nurse practitioners and clinical nurse specialists are not covered for assisting-at-surgery.
Physician Extenders
MHCP covers health services provided by a physician extender under the supervision of the physician.
Physician extender services are not covered unless they replace or substitute for the physician service.
Physician Extender: PA or APRN who chooses not to enroll with MHCP, genetic counselor, registered
nurse, licensed acupuncturist or pharmacist who is in one of the following professional environments:
 Employed by the physician provider
 Employed by the same provider organization that employs the physician

Supervised by a physician
Registered Nurse (RN): A nurse licensed under and within the scope of Minnesota statutes.
Genetic Counselor or Geneticist: A person who is board certified by the American Board of Genetic
Counseling (ABGC).
Supervision of Physician Extenders (Except PAs)
The process of control and direction by which the physician accepts full professional responsibility for the
supervisee, instructs the supervisee in their work, and oversees or directs the work of the supervisee. The
process must meet the following conditions:
 The physician must be present, available, and on the premises more than 50 percent of the time
when the supervisee is providing health services.
 The diagnosis must be made by or reviewed, approved, and signed by the physician.
 The supervisee may develop the plan of care for a condition other than an emergency, but it must be
reviewed, approved, and signed by the physician before care begins.
 The supervisee may carry out the treatment, but the physician must review and countersign the
record of a treatment within five working days after the treatment.
Role of Physician Extenders in Long Term Care (LTC) Facilities
Physician services provided by a physician extender in an LTC facility must be provided under the
direction of a physician who is an enrolled MHCP provider. This means the physician has authorized and
is personally responsible for the physician services performed by the physician extender and has
reviewed and signed the record of the service no more than five days after the service was performed.
Physician extenders may provide any service within their scope of practice and as delegated and directed
by a physician.
As permitted by Minnesota rules, licensure, and facility policy, APRNs or PAs who are not enrolled with
MHCP and are not employees of the facility (but are working in collaboration with a physician) may
provide the following physician services in an LTC facility:
 Develop a written plan of care as required by federal regulation
 Conduct a periodic visit as required by federal regulations. At the option of the physician, and in
accordance with facility policy, required visits (after the initial visit) may alternate between personal
visits by the physician and visits by a physician assistant or APRN
Genetic Counselor or Geneticist
A genetic counselor or geneticist may conduct a consultation to render an opinion or advice. The
following conditions apply:
 The genetic counselor or geneticist may only initiate diagnostic or therapeutic services at the request
of the attending physician.
 Follow-up consultations may be performed if it is medically necessary to reevaluate a recipient for
whom an opinion previously has been rendered.
 Consultations provided by a genetic counselor may be billed using 96040 or S0265.
Use of Modifiers
Do not use modifier U7 for a minimal service E/M code, as defined in CPT, because it represents a level
of service supervised by a physician but does not necessarily require his/her immediate ongoing
presence.
Use modifier U7 with all other E/M codes when the physician extender provides services, unless the
physician is directly involved more than 50 percent of the time that is required to provide the health
service.
Do not use modifier U7 for physician extender services associated with the enhanced prenatal care
services for "at risk" pregnancies. Refer to the Family Planning and Obstetrics & Gynecology Services
sections of MHCP Reproductive Health – Obstetrics and Gynecology policy.
Billing Physician Extender Services
Include the following for these services:
 Enter the NPI of the physician who supervised the service as the Rendering Provider
 Enter the appropriate procedure code for the level of care provided
 Enter the appropriate modifier
Noncovered Services
Services provided by personnel such as office and clerical workers, lab workers, assistants (for example,
surgical and ophthalmic) and aides are not considered physician extender services. These services are
considered part of a physician's overhead and cannot be billed separately.
Outpatient Hospital Services
Billing Requirements
Outpatient Hospital Clinic: For clinic services provided in an outpatient hospital setting, physicians must
bill the appropriate HCPCS/CPT code and use place of service 22. Failure to identify the place of service
as outpatient hospital services may be considered fraudulent or abusive billing, subject to monetary
recovery or program sanctions.
MHCP has designated specific HCPCS codes in which the individual code may be separated into
professional and technical components. Providers billing and delivering professional services in outpatient
hospitals will be paid for the professional component. The outpatient hospital will receive the technical
component in the form of a "facility fee."
Provider-Based Status for Clinics
Provider-based clinics are hospital owned clinics authorized with provider based status according to
federal regulations.
Billing
Professional Component
For this part of outpatient clinic services provided in a hospital owned clinic, bill professional services in
the MN–ITS 837P claim format using the appropriate HCPCS/CPT code; use place of service 22. Failure
to identify the place of service as outpatient hospital may be considered fraudulent or abusive billing, and
is subject to monetary recovery or program sanctions.
Facility Fee
For this part of outpatient clinic services performed in a hospital-owned clinic, bill facility fees in the MN–
ITS 837I claim format using the appropriate revenue and HCPCS/CPT coding.
Urgent Care in Emergency Department: Non-emergency care provided in an emergency department is
urgent care and must be billed as urgent care services.
Emergency Department: Emergent care provided in an emergency department is emergency care and
must be billed as emergency services. If, in a physician's professional opinion, emergency treatment for
the patient's condition cannot be provided in the emergency department, the physician may seek inpatient
admission certification for the patient and bill inpatient admission services. Refer to MHCP Inpatient
Hospital Authorization policy.
Hospital Physician Services
Eligible Providers
Physicians, APRNs, and PAs under the supervision of the physician under the physician and physician
assistant agreement and in accordance with the hospital by-laws, may provide inpatient hospital services.
Billing
Bill physician services provided in an inpatient hospital setting using the 837P: MN–ITS Interactive
(837P) Professional. Enter the dates of hospital admission and discharge in the Additional Dates field in
the Claim Information tab. If the recipient has not been discharged, do not enter a Discharge Date in the
Additional Dates field.
Evidence-Based Childbirth Program
Providers must complete the Non-participating Facility Births Evidence-based Childbirth Program (DHS6469) for all elective inductions between Jan. 1, 2012, and July 31, 2012, delivered in a hospital without a
hard stop policy in place.
For births on or after August 1, 2012, providers doing elective inductions prior to 39 weeks gestation no
longer have to submit the DHS-6469.
Refer to Evidence-Based Childbirth Program Policy in the Hospital section for a full explanation of the
evidence-based childbirth program policy.
Urgent Care Clinic Services
The following apply for urgent care clinic services:
 Urgent care clinic services are covered for MHCP recipients in an outpatient hospital setting.
 Urgent care services in a free standing facility (including physician clinics) must be billed as an office
visit.
 No facility fee is paid in a physician's clinic for after hours care.
Authorization Policy
Authorization is required for some MHCP covered services including all investigative procedures and
procedures that may be considered cosmetic. Refer to the PA Indicator column on the MHCP Fee
Schedule for procedures that always or sometimes require authorization.
Submit authorization requests to the Medical Review Agent. Authorizations are reviewed on a case-bycase basis.
The Medical Review Agent uses nationally recognized criteria to determine medical necessity. It is the
responsibility of the provider requesting authorization to submit sufficient documentation to establish that
coverage standards have been met. Certain situations may require a unique piece of information that will
aid the medical review agent in the decision-making process. Since it is impossible to identify all of the
diverse information necessary for each case, a request will be made for additional information as the
situation requires.
Investigative Procedures: A health service that has progressed to limited human application and trial,
lacks wide recognition as a proven and effective procedure in clinical medicine as determined by the
National Blue Cross and Blue Shield Association Medical Advisory Committee, and used by Blue Cross
and Blue Shield of Minnesota in the administration of their program using the following criteria:
 The technology must have final approval from the appropriate government regulatory bodies.
 The scientific evidence must permit conclusions concerning the effect of the technology on health
outcomes.
 The technology must improve the net health outcome.
 The technology must be as beneficial as any established alternatives.
 Improvement must be attainable outside the investigational settings.

A drug or device that the United States Food and Drug Administration (FDA) has not yet declared
safe and effective for the use prescribed. For purposes of this definition, drugs and devices are those
identified in the Food and Drug Act.
Plastic and Reconstructive Surgery
If staged plastic and reconstructive surgery is being proposed for correction of a congenital anomaly, the
complete plan for future surgeries must be submitted with the first authorization.
Botulinum Toxin
Review Authorization Criteria for use of Botulinum toxin, Type A or Type B.
Male Circumcision
MHCP only covers male circumcision when the procedure is medically necessary (in the opinion of the
attending physician, a pathologic condition exists where circumcision is required), and it is approved by
authorization. Refer to MHCP Authorization policy for prior authorization process.
Hysterectomy
Please refer to the MHCP Provider Manual Reproductive Health Hysterectomy section and to the MHCP
Authorization policy for prior authorization process.
Transplant Services
Covered Services
MHCP coverage for organ and tissue transplant procedures is limited to those procedures covered by the
Medicare program or approved by the DHS consulting contractor.
MHCP policy includes the following: transplant types:
 Autologous pancreatic islet cell transplant (after pancreatectomy)
 Kidney
 Liver
 Heart
 Lung
 Cornea
 Heart-lung
 Pancreas
 Pancreas-kidney
 Intestine
 Intestine-liver
 Stem Cell
Transplant coverage includes: preoperative evaluation, recipient and donor surgery, follow-up care for the
recipient and live donor, and retrieval of organs, tissues. All transplant related services are billed under
the recipient’s ID number. Refer to the Transplant Authorization Code (PDF) List.
Eligible Providers
Transplants provided to Medicare/Medicaid dually eligible recipients must be performed in a Medicare
certified transplant facility.
All organ transplants must be performed at transplant centers meeting United Network for Organ Sharing
Criteria (UNOS) or be Medicare Approved Heart, Lung, Heart-Lung, Liver, and Intestinal Transplant
Centers.
Stem cell transplants must be performed in a tissue transplant center which is certified by and meets the
Foundation for the Accreditation of Cellular Therapy (FACT) for stem cells or bone marrow transplants, or
be approved by the Advisory Committee on Organ and Tissue Transplants.
All transplant procedures must comply with all applicable laws, rules, and regulations governing all three
of the following:
(1) Coverage by the Medicare program
(2) Federal financial participation by the Medicaid program
(3) Coverage by the MA program. All transplants performed out of state must have prior authorization.
It is the responsibility of the transplant center to submit their certification documentation to provider
enrollment.
Eligible Recipients
Transplant coverage applies to MA and MinnesotaCare recipients. MinnesotaCare recipients should be
referred to their county human services agency for application to MA. If a recipient is not eligible for MA,
any maximum benefit limits applicable to the MinnesotaCare recipient will apply. Refer to the
MinnesotaCare section of the MHCP Health Care Programs and Services policy for further information.
People eligible for EMA are not eligible for organ transplant coverage or care services related to the
transplant procedure.
Authorization
Authorization is required for the following transplant procedures: stem cell, heart-lung, lung, pancreas,
pancreas-kidney, liver, intestine, intestine-liver, and autologous pancreatic islet cell transplant (after
pancreatectomy).
Transplant prior authorization request must be submitted to Authorization Medical Review Agent by the
physician rather than the transplant facility. The transplant facility may request documentation of the prior
authorization approval from the physician’s office or by calling the MHCP Provider Call Center at 651431-2700 or 800-366-5411.
The medical report must include the following information:
 Diagnosis, including ICD diagnosis code
 Proposed treatment
 Sufficient, pertinent information
If a transplant is to be performed out of state, the provider must obtain authorization prior to the service
being rendered. Refer to the instructions in the MHCP Authorization policy for out-of-state services. If the
procedure will be performed in an out-of-state hospital the prior authorization request must include
evidence that the hospital meets the requirements of Medicare, UNOS, and Foundation for the
Accreditation of Cellular Therapy (FACT).
Heart Transplant
Heart transplants are covered when performed in a facility on the Medicare list of approved heart
transplant centers.
Artificial heart transplants are not covered.
Heart-Lung Transplant Coverage
Heart-lung transplants for persons with primary pulmonary hypertension are covered when performed in a
Minnesota facility that meets UNOS criteria to perform heart-lung transplants. Heart-lung transplants
require authorization (except for those performed on recipients with Medicare coverage).
Lung Transplant Coverage
Lung transplants using cadaveric donors and lung lobe transplants from living donors are covered when
performed in a Minnesota facility that meets UNOS criteria to perform lung transplants. All lung
transplants require authorization (except for those performed on recipients with Medicare coverage).
Kidney Transplant Coverage
Kidney transplants must be performed in a hospital that is a participating provider of the Medicare
program. If performed in an out-of-state facility, kidney transplants require authorization prior to the
service being rendered.
Pancreas and Pancreas-Kidney Transplant Coverage
Pancreas transplants for uremic diabetic recipients of kidney transplants and people with hypoglycemic
unawareness, are covered when performed in a Minnesota facility that meets UNOS criteria to perform
pancreas and pancreas-kidney transplants. All pancreas and pancreas-kidney transplants require
authorization.
Liver Transplant Coverage
Liver transplants in children (under age 18) with extrahepatic biliary atresia, or other forms of end-stage
liver disease are covered.
Liver transplants for children with a malignancy extending beyond the margins of the liver, or those with
persistent viremia are not covered.
Liver transplants using live donors are covered.
Liver transplants are covered for adults with one of the following conditions:
 Primary biliary cirrhosis
 Primary sclerosing cholangitis
 Post necrotic cirrhosis, hepatitis B surface antigen negative
 Alpha-1 antitrypsin deficiency disease
 Wilson's disease or primary hemochromatosis
 Alcoholic cirrhosis
 Any other end-stage liver disease other than hepatitis B
 Hepatocellular carcinoma
 End-stage liver disease with the diagnosis of hepatitis B
In cases involving alcoholic cirrhosis, the following conditions apply:
 The facility must state its criteria for the period of abstinence required prior to surgery.
 Documentation must show how the patient meets that criteria.
 Documentation must show evidence of social support to assure assistance in alcohol rehabilitation
and immunosuppressive therapy following the surgery.
Liver transplants require authorization, including those covered by other third-party payers. Transplants
for recipients with Medicare coverage do not require authorization.
Intestine Transplant Coverage
Intestine transplants for a patient with a diagnosis of short bowel syndrome, parenterally dependent and
experiencing life-threatening or potentially life-threatening complications due to the original disease or to
complications of total parenteral nutrition (TPN), are covered. Intestine transplants must be performed in
a facility that meets UNOS criteria to perform this transplant. All intestine transplants require
authorization.
Intestine-liver Transplant Coverage
Intestine-liver transplants are covered for people who develop liver disease secondary to TPN treatment.
Intestine transplants must be performed in a facility that meets UNOS criteria to perform this transplant.
Intestine-liver transplants require authorization.
Stem Cell Transplant Coverage
Stem Cell Transplantation: A procedure where stem cells are obtained from a donor's or recipient's
bone marrow or peripheral blood, and prepared for intravenous infusion. DHS follows Medicare guidelines
and is replacing references to bone marrowtransplantation with stem cell transplantation.
Policy
Transplant centers must be participating providers of the Medicare program, meet Foundation for the
Accreditation of Cellular Therapy (FACT) criteria for stem cell transplants, and be located in Minnesota or
contiguous counties to receive payment for stem cell transplants.
All stem cell transplants require authorization.
Allogenic stem cell transplants are covered for the treatment of leukemia or aplastic anemia when it is
reasonable and necessary for the individual patient to receive this therapy.
Autologous Pancreatic Islet Cell Transplant (after pancreatectomy) Coverage
Autologous pancreatic islet cell transplant (after pancreatectomy) coverage is not to be confused with
pancreatic islet cell allograft transplant (noncovered) for a recipient with a diagnosis of Type I diabetes.
Pancreatectomy is covered for a recipient with a diagnosis of chronic pancreatitis with intractable pain.
With pancreatectomy, the pain is relieved, but without the autologous pancreas islet cell transplant, the
result is insulin dependent diabetes mellitus. The autologous pancreatic islet cell transplant has the
potential to prevent diabetes or make the diabetes mild. This procedure is covered when performed in a
Minnesota facility that meets UNOS criteria. All autologous pancreatic islet cell transplants (after
pancreatectomy) require authorization.
Billing Transplants
The cost of organ, tissue, and stem cell procurement should be included on the inpatient hospital claim.
The hospital stay for the donor is included in the DRG payment for the donee (MHCP recipient). All
charges for the donor should be billed using the donee's recipient ID number.
Other Payers
Liable third-party coverage monies must be used to the fullest extent before MHCP payment will be made
for a transplant. If payment is denied by a third-party payer, the denial and documentation of efforts to
secure payment must be submitted with the claim. If appeals are available through the insurer, DHS will
ask the recipient to pursue these appeals. Providers must obtain authorization for transplants that require
authorization even though private insurance may pay a portion of the charges.
Sleep Testing
Sleep studies include selected diagnostic and therapeutic services provided for sleep-related disorders.
In-lab sleep studies or polysomnograms are covered by MHCP. Document medical necessity in the
recipient’s medical record.
Eligible Providers
A sleep specialist must administer an in-lab sleep study or polysomnogram t.
Eligible Recipients
MHCP will cover sleep studies for recipients with the following conditions:
 Diagnosis of obstructive sleep apnea and other sleep-related breathing disorders
 Neuromuscular disorders with sleep-related symptoms that are not adequately diagnosed through:



 Sleep history
 Assessment of sleep hygiene
 Review of sleep diaries
Suspected narcolepsy
Parasomnias (cases of dangerous, violent or injurious behavior, seizure cases with inconclusive
EEG, and atypical parasomnias)
Periodic limb movement disorder (PLMD)
Covered Services
Sleep testing must be:
 Conducted in a sleep laboratory
 Attended by a trained sleep specialist
 Conducted following a careful exam and history that includes a standardized questionnaire
Attended in-home (portable) studies will be covered only in cases where the patient is unable to undergo
an in-lab study due to circumstances such as:
 Nonambulation
 Severe and persistent mental illness
Noncovered Services
MHCP will not cover unattended home sleep studies because they are considered investigative and not
medically necessary.
Billing
Bill sleep testing services in the MN–ITS 837P claim format using the appropriate HCPCS/CPT code(s).
Medical Nutritional Therapy (MNT)
Medical Nutritional Therapy (MNT) is a preventive health service designed to assess and minimize the
problems hindering normal nutrition, and to improve the patient's nutritional status. MNT services may be
provided in a physician's office, clinic, or outpatient hospital setting. Medical necessity must be
documented in the recipient’s medical record.
Licensed dieticians and licensed nutritionists enrolled with MHCP may provide MNT & Diabetic Outpatient
Self-Management (DSMT) services for MHCP fee-for-service (FFS) recipients when prescribed or
referred by a physician.
The medical professionals who may prescribe or refer recipients for MNT & DSMT services include:
 Physicians
 Advanced practice registered nurses
 Clinical nurse specialist
 Nurse practitioner
 Nurse midwife
 Physician assistant
Providers should contact the managed care organization (MCO) provider services call center about
coverage before providing services to MHCP recipients enrolled in an MCO.
Eligible Providers


Licensed detician
Licensed nutritionist
Eligible Recipients
MA and MinnesotaCare recipients are eligible for MNT.
MNT is a preventive health service and is not a covered service under the following programs:
 Emergency Medical Assistance (EMA)
 MinnesotaCare limited benefit (MLB)
Covered Services
Covered services include the following:
 Evaluation
 Follow-up
 Group counseling prescribed by a physician
Weight Loss Services
MHCP covers physician visits, medical nutritional therapy, mental health services*, and laboratory work
provided for weight management. Services must be billed by enrolled providers on a component basis
with current CPT codes.
If an MHCP recipient elects to participate in a weight loss program, the recipient may be billed for
components of the program that are not covered, as long as the recipient is informed of charges in
advance.
*Authorization may be required for mental health services. Refer to MHCP Mental Health Service policy
for requirements.
MHCP does not cover the following weight loss services:
 Weight loss services on a program basis
 Nutritional supplements or foods for the purpose of weight reduction
 Exercise classes
 Health club memberships
 Instructional materials and books
 Motivational classes
 Counseling or weight loss services provided by persons who are not MHCP providers
 Counseling that is part of the physician's covered services and for which payment has already been
made
 Nutritional counseling for diabetic education when it is part of a diabetic education program (see
Diabetic Education section)
Billing
MHCP reimburses dietician or nutritionist services only when prescribed by a physician and provided in
an office or outpatient setting. MNT and DSMT are separate benefits and may not be billed for the same
date of service. Payment for medical nutritional therapy is limited to the following codes:
 97802: Initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
This code is to be used only once per year, for initial assessment of a new patient
 97803: Reassessment and intervention, individual, face-to-face with the patient, each 15 minutes.
Use this code for all individual reassessments and all interventions after the initial visit when there is a
change in the patient's nutritional status
 97804: Group (2 or more), each 30 minutes
 Note: For medical nutrition therapy assessment or intervention performed by a physician see
Evaluation and Management or Preventive Medicine service codes G0270: Reassessment and
subsequent intervention following second referral in the same year due to change in diagnosis,
medical condition or treatment regimen, individual, face-to-face with patient, each 15 minutes
 G0271: Reassessment and subsequent intervention following second referral in the same year for
change in diagnosis, medical conditions or treatment regimen, group (2 or more), each 15 minutes
MHCP Enrolled Providers
Billing
Licensed dieticians or nutritionists in private
practice
Licensed dieticians or nutritionists who contract
with a private agency to provider services
Licensed dieticians or nutritionists employed by
hospitals, public health or community health clinic,
clinic, or an individual physician
Use your NPI as the billing provider and the
rendering provider.
To directly receive payment: Use your NPI as the
billing provider and the rendering provider.
If the private agency receives payment: It must
be an enrolled MHCP Provider. Use the private
agency’s NPI as the billing provider, and the
dieticians or nutritionists NPI as the rendering
provider.
Use the hospital, public or community health clinic,
clinic, or individual physicians NPI as the billing
provider, and the dietician’s or nutritionist’s NPI as
the rendering provider.
<br>
If services are rendered somewhere other than the listed billing provider address or in the recipient’s
home, include the Service Facility Location name, address NPI #, or the qualifier 1D, followed by their 9digit MHCP ID.
Diabetic Self-Management Training (DSMT) Services
Diabetic Self-Management Treatment (DSMT) Services: A preventative outpatient health service for
people diagnosed with diabetes. An outpatient diabetes self-management and training program includes
education about self-monitoring of blood glucose, diet and exercise, and insulin treatment plan developed
specifically for the patient who is insulin-dependent, and motivates patients to use the skills for successful
self-management of diabetes. Diabetic outpatient self-management training services minimize the
occurrence of disease and disability through instructions on maintaining health and well-being of the
patient.
Eligible Providers
The following are eligible to provide diabetic self-management services:
 Diabetic care instructions may be provided by a physician or RN.
 Nutritional counseling may be provided by a physician, licensed dietician or licensed nutritionist.
Referrals should be made to licensed dieticians or licensed nutritionist for in-depth nutritional
counseling.
 Licensed registered nurses may provide nutritional counseling only to the extent that their scope of
practice and education experience allow.
A provider of dually eligible MHCP recipients must be a "certified provider" according to Medicare's
definition. Certified providers for Medicare's purposes must meet the National Diabetes Advisory Board
Standards.
Eligible Recipients
MA and MinnesotaCare recipients are eligible for diabetic self-management services.
DSMT is a preventive health service and is not a covered service under the following programs:
 Emergency Medical Assistance (EMA)
 MinnesotaCare limited benefit (MLB)
Covered Services
A physician must order all diabetic DSMT services. DSMT services include the followign:
 Diabetes overview
 Type of diabetes
 Blood glucose testing
 Blood glucose self-monitoring education
 Insulin treatment plan for patients who are insulin dependent
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 Foot, skin, and dental care
Diabetes Management
 Stress and psychosocial adjustment
 Family involvement and social support
 Medications; Monitoring and use of results
 Prevention, detection, and treatment of chronic complications
 Prevention and treatment of low and high blood sugar
 Benefits, risks, and management options for improving glucose control
Nutritional counseling
 Meal planning, carbohydrate counting, label reading
 Dietary fat and cholesterol modification
 Role of fiber on blood sugar and cholesterol control
Exercise and activity
 Relationships between nutrition, exercise, medication, and blood glucose levels
 Behavior change strategies, goal setting, risk factor reduction, and problem solving
Other
 Preconception care, pregnancy, and gestational diabetes
 Use of health care system and community resources
Billing
Do not bill nutritional counseling, office visit (E/M) codes, facility codes, or other procedure codes with
DSMT codes. Use one of the following DSMT codes when billing, as appropriate:
 G0108: Diabetic outpatient self-management training services; individual session; 1 unit equals 30
minutes of training.
 G0109: Diabetic outpatient self-management training services; group session; 1 unit equals 30
minutes of training.
Bill one unit per each 30 minutes of DSMT services, with a maximum of not more than 10 hours within a
continuous 12-month period for each recipient. After the initial training, additional DSMT services are
limited to one session (group or individual) no longer than two hours in length per year.
Nutritional Products
Nutritional Product: A commercially formulated substance that provides nourishment, and affects the
nutritive and metabolic processes of the body. Nutritional products are covered by MHCP.
Providers
A parenteral nutritional product must be dispensed as a pharmacy service as prescribed by a physician.
Refer to MHCP Pharmacy Services policy.
An enteral nutritional product may be supplied by a pharmacy, home health agency, or medical supply
provider with a written physician's order.
Covered Nutritional Services
MHCP covers enteral nutritional products when the recipient's diagnosis can be linked to the need for a
nutritional product. Refer to MHCP Equipment and Supplies policy, for additional information.
Podiatry
Providers
Podiatrists who practice as defined in Minnesota Statutes 153 and physicians are eligible for payment for
podiatry services.
Covered Services
The following are covered services for podiatry:
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Debridement or reduction of pathological toenails, and of infected or eczematized corns and calluses
Avulsion of nail plate
Evacuation of subungual hematoma
Excision of nail and nail bed
Reconstruction of nail bed
Other non-routine foot care
Payment Limitations for Debridement or Reduction of Nails, Corns and Calluses
Payment for debridement or reduction of non-pathological toenails, and of non-infected or noneczematized corns or calluses is limited to the services defined in MN Rule 9505.0350 Subp 3. These
services are considered routine foot care, unless the patient has a systemic condition that may require
the expertise of a professional.
Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral
vascular diseases most commonly represent the underlying conditions that may justify coverage for
routine foot care:
 Diabetes mellitus
 Arteriosclerosis obliterans
 Buerger's Disease (thromboangiitis obliterans)
 Chronic thrombophlebitis
 Peripheral neuropathies
 Ulcerations or abscesses complicated by diabetis or vascular insufficiency
 Medical conditions which prevents self-care of these services
Noncovered Services
The following list includes, but is not limited to, podiatry services that are not covered by MHCP:
 Surgical assistant services (differing from assisting surgeons)
 Local anesthetics that are billed as a separate procedure
 Operating room facility charges
 Routine foot care:
 Foot hygiene (cleaning and soaking the feet to maintain a clean condition)
 Cutting or removal of corns and calluses (except as noted above)
 Trimming, cutting, clipping or debriding of nails (except as noted above)
 Use of skin creams to maintain skin toner
 Any other service performed in the absence of localized illness, injury or symptoms involving the
foot
 Services not covered by Medicare, or services denied by Medicare:
 Subluxation of the foot
 Treatment of flat feet
 Routine foot care
 Stock orthopedic shoes, except when attached to a leg brace
 Routine supplies provided in the office. Refer to List of Routine Supplies section.
Coverage Limitations
The following coverage limitations apply to podiatry services:
 When a physician or podiatrist provides services to long-term care (LTC) facility residents all of the
following are required:
 The referral must result from the resident, an RN, or LPN employed by the facility, the resident’s
family, guardian, or attending physician
 The LTC facility must document the referral in the medical record
 LTC facilities are responsible for routine foot care
 Coverage for the debridement and reduction of nails, corns, and calluses are limited to once every 60
days
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
For established patients, a podiatry visit charge must not be billed on the same day as the date for
services described for debridement or reduction of nails, corns, and calluses
The provider may bill the avulsion and excision codes only once per nail
Billing
For more information about billing for podiatry services, see the following:
 Refer to the Billing Policy chapter for podiatry services billing instructions.
 National foot care modifiers are required on all routine foot care services, regardless of specialty
 Refer to the Laboratory/Pathology, Radiology and Diagnostic Services section for billing instructions
Refer to the RSC-TCM section for Relocation Services Coordination and Targeted Case Management
information.
Legal References
Minnesota Rules 9505.0325 (nutritional products)
Minnesota Rules 9505.0330 (outpatient hospital)
Minnesota Rules 9505.0345; 9505.0355 (general information)
Minnesota Rules 9505.0350 (podiatry)
Minnesota Rules 9505.5010 (prior authorization)
Minnesota Rules 9505.5035 (second medical opinion)
Minnesota Statutes 147A.01 (physician assistant)
Minnesota Statutes 148.624 Subd 1 (Licensed Dietician)
Minnesota Statutes 148.624 Subd. 2.(Licensed Nutritionist)
Minnesota Statutes 153 (podiatry licensing)
Minnesota Statutes 256B.0625, subd.3; subd.4 (general information)
Minnesota Statutes 256B.0625, subd.4a (second medical opinion)
Minnesota Statutes 256B.0625, subd.25 (physician assistant standards)
Minnesota Statutes 256B.0625, subd.27; 256B.0629 (organ transplants)
Minnesota Statutes 256B.0625, subd.28 (nurse practitioner)
Minnesota Statutes 256B.0625, subd. 28a
Minnesota Statutes 256B.0625, subd.32 (nutritional products)
Minnesota Statutes 256D.03, subd.7 (second medical opinion)
42 CFR 413.65 (provider-based clinics)
42 CFR 440.130 (c) (preventive services definition)
42 CFR 440.166 (nurse practitioners services)
42 CFR 440.20 (outpatient hospital and rural health services)
42 CFR 440.50 (services: general provisions)